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‘Bothering’ Your Doctor

By Tara Parker-Pope March 17, 2008 2:23 pmMarch 17, 2008 2:23 pm

Does the medical system try to prevent you from “bothering” your doctor?

That’s a question Sacramento physician Dr. Faith Fitzgerald mulled recently as she attempted to notify another physician about a health crisis involving one of his patients. She chronicles her futile effort to phone a fellow doctor in an essay that appeared in last months’ Annals of Internal Medicine.

The patient was a secretary at the University of California, Davis, where Dr. Fitzgerald works. The woman staggered into her office with a headache and feeling faint. She ended up in the intensive care unit of a nearby hospital, and Dr. Fitzgerald called the woman’s regular physician to let him know what had happened.

But instead of speaking to her colleague, she was blocked by a medical culture seemingly designed to prevent anybody from actually contacting a doctor while at work. Dr. Fitzgerald first ended up in an automated phone system. When she finally reached a live human, she was put on hold more than once, transferred to another operator for a futile attempt at paging the doctor, then sent back to the original operator before eventually being hung up on.

Dr. Fitzgerald gave up, but the incident left her thinking about her own patients and co-workers who often apologized for “bothering” her. In her essay, she writes about how she once instructed the nursing staff to contact her about any change in a terminal patient’s condition, but nobody called her when the patient died. “It was late last night, I didn’t want to bother you,’’ the nurse said. Dr. Fitzgerald says that when a patient calls, the conversation always starts with, “I hate to bother you, but …”

And she notes, with irony, that nobody ever apologizes when they notify her about an academic committee meeting she must attend. “Committees are important,’’ she writes.

“I tell my patients, residents and students that they should call me if they need me. They are not an interruption to my work; they are my work. In this sense, I can’t be ‘bothered’ by them. But a system and a culture designed to protect doctors from their patients assume I am bothered, and so give that same impression to those trying to reach me. This really bothers me.’’

I’ve often thought that doctors should make use of email to communicate with their patients. I have a close friend of mine who was my therapist. I would love to communicate with him by email but he is reluctant to do this with his former patients.

I think in certain fields, especially psychiatry, where patients can have moments of depression or anxiety or loneliness (cancer patients can also have these), it is important to be able to communicate with your therapist rather than having to leave a voice mail or having to “go to the nearest emergency room” as psychiatrists advise if they are not in the office.

Particularly if a patient does not come in for an appointment or cancels one, the doctor would have time to send an email to another patient who wants to be able to communicate with him outside the office. Also, it might take less time for a physician to email patients rather than listening to endless voice mails from them, then taking the time to call back.

Also, I would like to read Dr. Fitzgeralds’ full article. Would it be possible for her to make it available for readers of this blog or to convince the journal to make it available without a subscription?

And yet, Doctors become annoyed when patients turn to Googling their medical condition.

All my docs have the phone maze, and what’s most frustrating is that I have to sit through a litany of options that don’t apply to an English-speaking established patient. It’s a devaluation of my time and the very first option in the menu should be to put an established patient through to a human. I know from my parents’ experiences that these phone mazes are very confusing and a real barrier to the elderly being able to get through to their doctors’ offices.

I’ve found that a written letter marked “non-urgent” sent via snail mail works best for non-emergency questions/concerns. I think that the docs are just overwhelmed with questions coming in from all directions.

It is an unusual doctor who does not give the impression of being bothered even during an appointment, let alone over the phone. Several of the better doctors I see for myself or my family either stand by the door (or halfway out of it) while talking to us or talk so fast that I can’t parse their meaning quickly enough to ask questions. Only our kids’ pediatrician seems willing to fully come into the room, answer questions and not make us feel as though we’re bothering her. It’s good to see a doctor address this issue.

Most of my family members are doctors and as far as I can see, none of their patients or nurses or residents have any problems paging any time of the day, night, holidays and vacations. In fact, I cannot recall a single week when my wife or my siblings or parents were able to sleep the entire night without being paged. Since most of my familiy are doctors, a number of our friends are doctors and I guess with the exception of a couple of dermatologists, most get paged more times than they care to remember, half the time for no reason. My point is, and it applies to most of the articles, is that everyone has an opinion. This was an opinion of one doctor who could not get a hold of another. Honestly, I don’t even buy it. Every doctor I know has a pager and a cell phone and their office staff know how to reach them. This would be especially true if another doctor is paging. Btw, why would a Dr. herself spend so much time reaching anotehr dr. in question and not delegate it (to see other patietnts, perhaps)? Based on my experience, you just page and wait for the other doctor to call you back, you don’t play the phone game, but then again, she is in an academic environment and she has to publish something, I guess this counts towards the list of articles.

From TPP — If you read the full article, you’ll see she tried to page but was informed paging didn’t work when the doctor was in clinic.

I just looked up the original article since I have access to Annals and all I can say is WOW. 99.srob should definitely read it if he/she has any doubt that the Dr. tried everything she could. Unfortunately, I can’t say this particularly surprises me given my own experience with doctors. Just one more thing contributing to the overall problem with health care in this country I guess.

From TPP — Yes i wish it had been free. Impossible to capture how much effort she went to and the ridiculous response she got from hospital operators.

This is an ongoing problem for patients but I did not realize that doctors can’t even talk to their colleagues. I will not stay with a doctor who is difficult to reach, no matter how good the doc is supposed to be. If I can’t reach the doc, it really doesn’t matter if he/she is good.

I prefer to send emails or faxes because I worry that when I leave a voice message with office staff, it may not be transmitted to the doctor correctly. Sometimes it is perfectly fine for a nurse or other staff to return the call, fax, or email but not always.

I feel it is reasonable to expect a reply before the end of the day. If the request is made toward the end of the day, then a call the next morning is reasonable. If the doc is out of the office, then it should be possible to reach a covering doc.

The absolute most annoying thing is calling after hours and getting a message directing the patient to call 911 or go to an emergency room; otherwise wait until office hours.

If I call after hours, the problem is very important but it does not mean that the appropriate thing to do is to avail myself of emergency services.

There is so much written about people who access emergency facilities inappropriately. It is a shame that doctors contribute to this problem.

Doctors say that they are not compensated for correspondence. Time spent on correspondence takes time away from billable services. The truth is that the fee for the office visit includes the additional correspondence.

Doctors can keep correspondence under control by giving patients carefully explained written instructions, answering questions during the visit,
and in general, by not rushing through the appointments. Unfortunately, the doctors are motivated to minimize duration of visits because the more patients seen in an hour, the higher the billing.

Doctors are wont to point out that other professionals such as lawyers get paid by the hour and that they bill for correspondence. That is certainly not always the case. Many lawyers find that clients will only pay a flat fee. If a client wants a will, the first question is going to be “How much will it cost?” An hourly rate figure is a deal breaker in many instances.

In my CPA practice, the same thing was true and if business was bad, I was often asked to take a cut.

Managed care does reduce doctors’ income but they are not forced into the contracts. Indeed, many doctors to not accept insurance. For the rest of us, the economy itself restricts income.

Very interesting and important issue. Having practiced in both an academic and private setting, I too was amazed by this story. [I did not pay to read the entire article either.] We were unusual in having a PERSON answer the phone directly in our office, and in off hours an answering service would take messages and page the covering physician as indicated, but all physicians need to have controlled availability.

When physicians are with patients (who usually should have uninterrupted discussion, unless there is a true urgency) most physicians have someone screening the calls to decide when interruption is appropriate and to prioritize return calls (by staff person or physician). In our office we often did interrupt to take calls from other physicians when they were actively involved in caring for a patient we also were seeing.

When supervising resident physicians and fellows in training (or nurses in any setting) it was understood that we encouraged them to handle issues that they were virtually certain were being handled in accord with our standards, BUT that whenever they were NOT SURE, they should call so we could discuss the situation (or even go there to consult). Most residents prided themselves in their increasing competence, but also realized the limitations. They would usually check first with more senior trainees, but usually realized that there was no shame in calling the attending physician when appropriate AND important to avoid assuming more responsibility than they should.

Patients who think they do not have adequate access to staff (that are directly in touch with their physicians) should discuss it with the physician. IF that discussion is not satisfactory, find another physician.

Due to a change in insurance, I’m looking for a new GP and chick-inspection doc. It’s funny, because when I put up a post on a local web group, one of the first things on my list was ‘Accessible’.

I’ve had docs I couldn’t reach, and it cheeses me right off. I don’t mean that every time I call the office with a hangnail, day or night, someone should immediately put me in contact with a doctor. I mean that if something serious happens, I should be able to get hold of my doc within a few hours, or the next morning at the very latest. If he’s on vacation, fine, but put me in touch with the person covering his patients.

My boyfriend had a prescription medication refill held up because the doctor ‘wanted to talk to him about something before authorizing it’ and just kept ignoring the fax approvals from the pharmacist so my boyfriend would call him. But when he called the office, he got put on hold, shunted through menus, hung up on, and connected to the wrong person. All the while, going without his allergy meds for several days. What did they want to talk to him about? “Hey, we’re confirming all our address files, and we wanted to make sure we have your right address and phone number.”

I don’t know that it’s all the fault of the doctors, though. Receptionists and office personnel often get the directive to “manage the doctor’s time” and don’t really have the skills or instructions to triage patient calls. HMOs and clinics and hospitals, in the name of ‘freeing’ up a doc’s time, develop Byzantine strategies for controlling access.

Many years ago, my mom called my doctor several times because I’d hit my right thumb on a post and it was swollen and blue. We called, the office gave us a runaround, and finally my mom took me down to the hospital to his office. We waited there for forty minutes, and then she walked me over to the ER – where we found my doctor, standing at the nurses’ station drinking a cup of coffee. He started to chew us out for coming to the ER instead of his office, and Mom let him have it with both barrels. Apparently, though, it was hospital policy not to page the docs unless it was a critical case down in the ER, and since he was *in* the ER, it never occurred to him that someone might want him for something that wasn’t on his schedule.

In my experience as a patient, this varies, depending on whether or not the doc is in private practice.

All of my private practice docs are easy to get a hold of. One has a voice message, as she has no staff, but that’s fine. She always responds quickly to messages. Another has a receptionist who answers the phone.

Docs in system settings, however — affiliated with hospitals, HMO, etc. — are very difficult to reach, if not impossible. And this has grown increasingly worse over the past 20 years.

I was shocked at a recent referral consult to a specialist to find that our 15 minute conversation was labeled “intensive.” He tapped my knees, felt them, looked at the x-ray and told me that I had bursitis which could not be treated. (Has to do with a tendon, unfortunately) That was our “intensive” meeting.

The requirement for breezy docs appears to come from high management, usually administrative — not from the docs themselves (especially since most of these docs are on salary, not fee.)

I’ve had goo success with asking to speak to my doc’s nurse. The nurse is usually available, and can answer my question, or grab the doc in a way neither I nor the receptionist can do.

When I wanted to be able to phone my doctor concerning a newly-discovered tumor, he cheerfully told me I would not be able to get through to him, but if I gave him my number he would try to phone me.

In the end it did not matter, however, because I found phone conversations with him so unsatisfactory that I decided to speak with him only in person. In due course, I decided I did not even want to see him in person. I haven’t figured out how to get a new physician without suffering the damage of creating bad feelings in this closely-knit Manhattan medical community.

As a specialist, I often have to contact other physicians. It can be easy, or impossible.

I have had many patients who ask me questions that are unrelated to my specialty simply because another specialist or the primary was not reachable. Sometimes the problem is urgent. I had one patient who felt palpitations and dizziness. She called us, because we were easier to contact. I am her allergist, yet I had to see her in the office with hypotension (low blood pressure) and call 911 to get her to the hospital. She was in the hospital for over a week due to sepsis (infection spread to the blood) that could have killed her.

#10, Ned — No need to worry about what your former & new doctors will think. Most doctors understand that no doctor can please every patient. I would simply find a new doctor, convey relevant details of your history, and omit any lengthy complaints regarding your former doctor. It’s fine if you need to state relevant facts that could be construed as complaints, but I suggest delivering them in as objective a manner as possible. The goal of your new physician will be to help you to manage your health and move forward. Hearing an extensive history of conflict (personality or otherwise) with your former physician will waste valuable office visit time and is not likely to assist your new physician in accomplishing her (or your) goals.

Want a doctor who responds to telephone calls promptly, treats individuals with respect, gives quality care, makes rounds regularly, is thorough, has not had series of malpractice suits? Ask a RN!
We see and hear all.

In this system, the more you bother your doctor, the lower the chance that he/she will actually inform you. But if you don’t talk with them, they won’t inform you. I guess the trick is to strike a balance between being an annoying, obnoxious jerk and a doormat who does whatever one is told.

The problem is that everyone wants a Ferrari when it comes to health care but will only pay for a used Hyundai. When people willingly pay more for a haircut than a doctors visit, what can be expected. Does anyone know the break even number of patients seen per hour for a regular Doctors office in New York is?
Think about it.

1. Call your doctor’s office.
2. Go through phone tree (also have to sit through the whole if this is an emergency, call someone who can do something about it spiel).
3. Receptionist answers, “asks” you to hold before you can get half of “hello” out.
4. Hold for 5 to 8 minutes.
5. Have another receptionist answer.
6. Half way through identifying yourself and your doctor, receptionist interrupts, asks you to hold.
7. 5 minutes later, first receptionist answers, requires you to identify yourself and your doctor, along with your reason for calling.
8. At this point, two things can happens—
8a. The receptionist tells you that your doctor will not be in the office for the next week, or just left for the day.
8b. The receptionist will take down your contact information, and tell you that someone will get back to you.
(note: do not be surprised if the above interaction takes place on speaker phone).
9. Several hours later, a nurse from your doctor’s office will call back. This will not be the nurse who weighed you and took your vitals at your last appointment. This will always be a new nurse, with whom you do not have a relationship.
10. You are compelled to describe your symptoms in graphic detail to this person you have just met, and never seen face to face. And because the nurse called you back, you will invariably be at work, or in the middle of the grocery store, or on the bus. And you will have to try to strike a balance between making your condition sound serious enough to warrant the doctor’s attention; and protecting your privacy in public. Good luck.
11. The nurse writes down your symptoms, asks you if you have been getting enough sleep, and suggests that you take a multivitamin.
12. The nurse tells you that she will show your doctor your symptoms, and your doctor will get back to you.
13. Three days later, your doctor will leave a voice mail message telling you that your symptoms don’t sound serious. But if you have any additional questions, feel free to return her call.

And return to step one.

This routine is especially fun when you are in pain, physically exhausted, or experiencing an inexplicable and debilitating symptom.

As a pediatrician I am used to constant interruptions by new parents.However, one Christmas on call I received two phone calls: one from a father who didn’t want to bother his physician with his symptoms but was fine with calling me, and one from a parent who wanted to know if I thought she could use her children’s antibiotics on the sick parakeet. And I am supposed to stay calm, pleasant, and professional at all times. . .

Kaiser Permanente encourages patients to email their doctors. Log onto KP.org then sign up for online services, you can see you lab results, book appointments, an email your doctors. They are tracked on how quickly they respond.

My doctor actually acts like you’re bothering her when you arrive for your annual physical. Amazing. Not sure why she still sees patients — perhaps to keep her credentials at a Harvard teaching hospital? Or she thinks she should?

I’d rather see the nurse practitioner, who looks you in the eye, remembers your name, and seems to genuinely care about your health. I’d switch but MGH hasn’t had a primary care physician open for new patients in two years. Ugh.

Glad that this article highlights how hard it is for patients to see/speak to a doctor. But sometimes once you get them in person, you’d rather get the recording :-)

If health care were a true market, these docs would be out of business years ago.

I think it is very frustrating to be given the ru-around by your doctor when you have an urgent concern, and doctors should be accessible to their patients.

The only caveat, that must be realized, however, is that no patient wants his or her doctor, if he or she gets a phone call, to suddenly leave during an important or uncomfortable exam or treatment. Respect must be given also the person currently being treated, and doctors cannot take all calls immediately. However, for doctors to respond as soon as they are no longer busy is a reasonable expecation.

I believe that email is a legitimate and efficient use of technology in medicine. However, some issues here need to be addressed, also. For one, if the doctor hasn’t actually seen the patient, there may be a greater risk of providing inaccurate advice, which could be harmful to the patient. Additionally, our litigious culture might discourage the doctor to give any advice without an in-person meeting.

Also, even if the emails are successful, there has to be a way for the physician to be fairly compensated for time he or she puts into answering what could end up being hours worth of emails. This is not a doctor get rich strategy- simply a fair realization that answering many patients’ questions over email diverts time from seeing patients, and may add a lot of extra time to a doctor’s working day. Of course, all medical issues should be dealt with before even thinking about compensation, but this must be a system that works fairly for both patients and doctors. This issue does not apply as much for people who pay a yearly fee for “full-service” doctors, because answered emails are part of what they pay for.

I am an ER nurse and if I need to ge in touch with someone’s physican I just do it. No apologies. It always annoys me when I hear another nurse or doctor apologize for for ” bothering” them. They need to get over it.

Every time I call or show up at my primary care doctor’s office, I am made to feel as if I am an interruption in an otherwise smooth-flowing day. I cannot get a response to any kind of query or emergency in less than 72 hours, and if I suggest that I expect otherwise, I suspect that yet another tick is made in my chart to suggest I am a diffcult patient. I have no direct access to my physician. Calls after hours are directed first to an operator, then to an advice nurse who has no connection to the practice and knows and understands nothing about my condition. I have had promises to send prescriptions to the drug store that have never been fulfilled, messages left that are never returned, tests taken whose results are never sent to me, but if I show up 8 minutes late for an appointment in the downtown of a major urban center where parking is as scarce as hen’s teeth, I lose my appointment – even though I travel 150+ days a year for my job and have a difficult time scheduling anything. Why don’t I feel connected to my doctor or believe that she has any interest in caring for me? Why don’t I feel that I have a partner in my health care? All I can say is, thank goodness that my chronic health care problem is controlled with drugs and that I don’t have diabetes, AIDS or any other disease that requires active management. And I just pray that my condition doesn’t have long term sequelae that I remain uninformed about because I am on my own as far as managing my own health care. Find another physician? I’d love to – have been looking for ten years.

I’m soooo lucky. I got pneumonia — and because of that a fabulous doctor. My former PC only had office hours on Mon & Thu (he practiced in different locations on the other days, and couldn’t be reached). I awoke one Wed morning with a 103 temp, severe chest pains, couldn’t breathe. I logged in to my insurance company (Oxford), clicked “find a physician,” entered my zip code. Voila! An MD right up the street. Despite being a brand new patient, he got me in within the hour, examined me, sent me for a chest X-ray, and called me at home that night with the results.

Two years later, I woke up on a Sunday with severe chest pains and extreme difficulty breathing. Toughed it out for most of the day (it being Super Bowl Sunday) and finally called around 6:30 PM. The voice message warned “make sure this is really an emergency because your call will be forwarded.” 45 seconds later he called me back; get to the emergency room, he said — I’ll call ahead and let them know you’re coming. Sure enough, I got there, they took me right in and an X-ray revealed a broken rib (done sleepwalking, they guess).

There is a kind of doctor who will call you back, Who will pick up the phone when you call with an emergency. It’s your small town vet. And because we do, we get people calling us about human problems in the middle of the night!

But seriously, we are a society that denigrates the importance of our own health. We go to work when we are sick, we grump when our co-workers are sick. Ergo, many feel like we are bothering the MD. And GP MDs are overworked and underpaid by and large. So, they set up screening systems to protect themselves from egregious clients. But, the rest of us get stuck in the system.